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Journal: Pain practice : the official journal of World Institute of Pain


INTRODUCTION: Susceptibility to pain varies among individuals and may predispose to a higher risk for pain disorders. Thus, it is of interest to investigate subjects who exhibit higher resistance to pain. We therefore tested pain tolerance and assessed personality traits of ultra-marathon athletes who are able to run 4487 km (2789 mi) over 64 days without resting days and compare the results to controls. METHODS: After approval of the local ethics committee and with informed consent, 11 participants of the TransEurope FootRace (TEFR09 participants) and 11 matched (age, sex, and ethnicity) controls without marathon experience in the last 5 years were enrolled. They were tested for cold pain tolerance (cold pressor [CP] test), and the 240 item trait and character inventory (TCI) as well as the general self-efficacy (GSE) test were obtained. RESULTS: TransEurope FootRace participants had a highly significant greater cold pain tolerance in the CP test than controls (P = 0.0002). While the GSE test showed no differences, the TCI test provided TEFR09 participants to be less cooperative and reward dependent but more spiritually transcendent than the controls. Significant positive correlations were found between the CP test pain score at 180 seconds and several TCI subscales showing that higher pain scores correlate with higher reward dependence, dependence, cooperativeness, empathy, and pure-hearted conscience. CONCLUSIONS: Personality profiles as well as pain tolerance of our sample of TEFR09 participants differ from normal controls and-as obtained in previous studies-probably also from chronic pain patients. Low pain perception may predispose a person to become a long-distance runner. It remains unclear, however, whether low pain perception is cause or consequence of continuous extreme training.

Concepts: Psychology, Informed consent, Personality psychology, Pain, Neuroticism, Chronic pain, Trait theory, Marathon


BACKGROUND: Patients in a palliative care trajectory frequently suffer from depression. To distinguish depression from normal sadness, the use of screening instruments could facilitate the diagnostic process. However, in palliative care, screening instruments may not discern physical symptom burden from psychological distress, due to the high number of physical symptoms in palliative patients. OBJECTIVES: The aim of this study was to explore physical symptom burden and psychological distress in patients with advanced cancer in relation to scores on screening instruments for depression. METHODS: Patients with advanced cancer were asked to fill out the Beck Depression Inventory (BDI-II), Beck Depression Inventory Primary Care (BDI-PC), Hospital Anxiety and Depression Scale (HADS), and Memorial Symptom Assessment Scale Short Form (MSAS-SF). The relationship between scores on screening tools for depression and different physical symptom clusters was explored. RESULTS: In the sample of 65 patients, screening instruments for depression correlated highly with different somatic symptom clusters. The BDI-II cognitive subscale was the only scale that was not significantly correlated with any of the somatic symptom clusters. CONCLUSION: Screening tools for the detection of depression in patients with advanced cancer may not provide an accurate evaluation of depression. These tools seem to measure physical symptom burden as well, especially when patients suffer from symptoms of the clusters fatigue/anorexia/cachexia, neuropsychology, debility, or pain. In this study, the BDI-II cognitive subscale seems to differentiate best from somatic symptom burden.

Concepts: Psychology, Cancer, Oncology, Symptoms, Palliative care, Symptomatic treatment, Suffering, Beck Depression Inventory


Neuropathic pain is a serious chronic condition strongly affecting quality of life, which can be relieved but cannot be cured. Apart from symptomatic management, treatment should focus on the underlying disorder. The estimated prevalence is at least 1% to 5% of the general population. Neuropathic pain is characterized both by spontaneous and evoked pain. A diagnosis of neuropathic pain can usually be established based solely on history and neurological examination. Ancillary investigations may include EMG and computerized tomography/magnetic resonance imaging scans, depending on the localization of the suspected lesion. A limited number of agents, primarily directed at symptom control, are currently approved for use in neuropathic pain. A mechanism-based approach to pharmacological intervention supports the use of polypharmacy in neuropathic pain.

Concepts: Medicine, Life, Greek loanwords, Neurology, Pain, Symptomatic treatment, Peripheral neuropathy, Neuropathic pain


A subcostal transversus abdominis plane (TAP) phenol injection was performed on a patient with refractory cancer pain due a metastatic involvement of the abdominal wall. A diagnostic block with local anesthetic was performed under ultrasound guidance (USG), resulting in a decrease of 80% and 100% in dynamic and static visual analog scale (VAS) for pain, respectively, for 20 hours. A phenol injection was then performed under USG. The patient reported 70% and 100% reduction in the dynamic and static VAS for pain and had a 50% decrease in the opioid requirement that was maintained for 2 months. TAP blocks offer an interesting tool for either diagnosis or therapeutic purpose in chronic pain management. USG provides an optimal approach to soft-tissue lesions where fluoroscopy techniques are not useful.

Concepts: Vitamin D, Anesthesia, Transversus abdominis muscle, Pain, Chronic pain, Ketamine, Local anesthetic, Iliohypogastric nerve


BACKGROUND: Chronic pain is distressing for patients and a burden on healthcare systems and society. Recent research demonstrates different aspects of the negative impact of chronic pain and the positive impact of successful treatment, making an overview of the costs and consequences of chronic pain appropriate. OBJECTIVE: To examine recent literature on chronic noncancer and neuropathic pain prevalence, impact on quality and quantity of life, societal and healthcare costs, and impact of successful therapy. METHODS: Systematic reviews (1999 to February 2012) following PRISMA guidelines were conducted to identify studies reporting appropriate outcomes. RESULTS: Chronic pain has a weighted average prevalence in adults of 20%; 7% have neuropathic pain, and 7% have severe pain. Chronic pain impeded activities of daily living, work and work efficiency, and reduced quality and quantity of life. Effective pain therapy (pain intensity reduction of at least 50%) resulted in consistent improvements in fatigue, sleep, depression, quality of life, and work. CONCLUSION: Strenuous efforts should be put into obtaining good levels of pain relief for people in chronic pain, including the opportunity for multiple drug switching, using reliable, validated, and relatively easily applied patient-centered outcomes. Detailed, thoughtful and informed decision analytic policy modeling would help understand the key elements in organizational change or service reengineering to plan the optimum pain management strategy to maximize pain relief and its stream of benefits against budgetary and other constraints. This paper contains the information on which such models can be based.

Concepts: Medicine, Management, Pain, Suffering, Chronic pain, Pain management, Neuropathic pain


Compounding pharmacies play an increasing and increasingly important role in our healthcare system, but recent media attention has exposed limited regulatory control over these organizations at the same time their role is expanding. Compounding pharmacies are not regulated in the same manner as pharmaceutical companies and are governed largely by Chapter <797>, a monograph on the pharmaceutical compounding of sterile products, issued but not enforced by the U.S. Pharmacopeial Convention. Not all states require adherence to Chapter <797>, and those that do may choose not to enforce it stringently. Furthermore, Chapter <797> is not a strong standard-for example, it does not require documentation of drug lot numbers or cross-references for patient identification. Thus, there have long been many potential quality issues associated with compounding pharmacies. As these compounding pharmacies provide important products and services, better regulation is urgently needed. Moreover, clinicians should be better aware that some injectable products they use may have been prepared by a compounding pharmacy.

Concepts: Pharmacology, Hospital, Pharmaceutical drug, Regulation, Pharmacy, Pharmacist, Compounding


Whether psychological factors such as anxiety and pain catastrophizing levels influence the expression of endogenous analgesia in general and, more specifically, the conditioned pain modulation (CPM) response is still under debate. It may be assumed that other psychological characteristics also play a role in the CPM response. The neurotransmitters serotonin, dopamine, and norepinephrine are involved both in CPM, as well as personality traits such as harm avoidance (HA), novelty seeking (NS), and reward dependence (RD), which can be obtained by the Tridimensional Personality Questionnaire (TPQ). However, the associations between these traits (HA, NS, and RD) with endogenous analgesia revealed by CPM have not yet been explored.

Concepts: Psychology, Neurotransmitter, Dopamine, Norepinephrine, Neuroticism, Temperament and Character Inventory, Tridimensional Personality Questionnaire, Reward dependence


Low back pain is very common, but the pathophysiology is poorly understood. We present a new hypothesis regarding the pathophysiology of common low back pain supported by our flexible endoscopic observations of the epidural cavity (epiduroscopy), anatomic dissection of embalmed and fresh cadavers, and careful review of preexisting information available on the anatomy of the epidural space and neuroforamen. A new approach to the treatment of common low back pain based on the hypothesis was developed and is presented in the case reports of five patients. Treatment focuses on a perichondrium derivative; the peridural membrane, which creates a suprapedicular compartment in the neuroforamen where we hypothesize inflammatory material accumulates. This produces common low back pain by causing inflammation and sensitization of the peridural membrane and periosteum that forms the boundaries of this compartment. Percutaneous Ablation and Curettage and Inferior Foraminotomy (PACIF(sm) ) aims to destroy the peridural membrane, denervate sensitive structures, and remove inflammatory tissues from the suprapedicular canal. The proposed mechanism of action and safety of PACIF(sm) is discussed in the context of epidural and neuroforaminal anatomy. As shown by the five case reports, PACIF(sm) appears to be highly effective and safe, warranting further evaluation.

Concepts: Scientific method, Low back pain, Back pain, Observation, Epidural, Dissection, Epidural space



Complex regional pain syndrome (CRPS) is a disorder that is often challenging to treat and can be associated with a prolonged course of severe pain. Therapy of CRPS remains controversial; the pain often can be very difficult to control, and treatment includes medications, physical therapy, regional anesthesia, and neuromodulation.

Concepts: Pain, Myofascial pain syndrome, Complex regional pain syndrome